Providers are pushing hard to have Kentucky throw out a long-standing policy that limits reimbursement for intensive chronic-care visits for Medicaid beneficiaries.
Patients suffering from several chronic conditions at once such as diabetes, heart disease and chronic obstructive pulmonary disease, tend to need longer office visits with a doctor than healthier individuals. In Kentucky, these longer visits are known as level four or five visits.
For years the state has allowed only a doctor to bill for such visits twice in a year per patient as a cost-containment measure. However, it is now considering striking the policy at the behest of providers and advocates, said Jill Midkiff, a spokeswoman for the state's Cabinet for Health and Family Services. She provided no timeline as to when a decision would be made.
Now, if a provider attempts to bill for more than two higher-level visits in a year for a patient, they'll receive the standard office visit rate, which can be as much as 60% less than a higher-level visit, according to some providers. Or they will not be paid at all.
While there are no hard estimates, anecdotally the number of Medicaid patients with multiple chronic conditions has increased in the state. More than 400,000 people joined Medicaid after the state expanded eligibility for the program under the Affordable Care Act. Now 1.3 million people, or nearly a quarter of the state's population, are in the program.
“There are so many new people coming into Medicaid, and a lot of these folks have comorbidities,” said Patrick Padgett, executive vice president of the Kentucky Medical Association. “More providers are saying if you want us to get these people healthier, you need to make sure we're properly compensated.”
Kentucky is the only state in the nation that limits how many times a provider can bill for a longer doctor visit, according to the American Association of Nurse Practitioners, which performed an analysis (PDF) on the policy.
Kentucky began switching most of its fee-for-service Medicaid population into managed care in 2012, and managed-care plans continued to limit payment to two higher-level visits annually. But that created new problems. The CMS urges providers to submit accurate claims and providers continue to bill for higher-level visits they provide, even after exceeding the annual two-visit maximum. Managed-care plans should convert the bill to one for lower-intensity visit codes, but plans have not being paying providers at all in some cases, said Nancy Galvagni, senior vice president at the Kentucky Hospital Association.
In other instances, providers receive surprise refund requests from the plans. Some of the refund requests are for significant amounts.
“Practices run on a very tight budget and these unexpected refunds, could in some instances, be enough to cause practices to close,” says a 2014 report on the issue by the Nursing Technical Advisory Committee (PDF), a group that advises the state on Medicaid.
Plans have some wiggle room on if they want to pay for more than two high-level visits. Passport Health Plan is the only one that places no restrictions on the visits.
“Passport does not limit expanded office visits to a certain number per year per member/patient, because Passport respects the medical opinion of its rendering providers as to the appropriate level of services provided to its members,” Michael Rabkin, a spokesman for the plan said in an e-mail.
Spokespeople from WellCare and Coventry Health Care say they are following state policy when restricting reimbursement of the higher-level visits. They didn't comment on claims of nonpayment. Spokespeople from Humana and CareSource did not return requests for comment.
The Advisory Council for Medical Assistance, a panel that advises the state on Medicaid, is planning to meet this month to discuss why some managed-care plans do not pay providers at all for higher level visits beyond the two allowed. No date has been set for the meeting.